Anna Stelter, LMSW, MPH
A national epidemic of opioid use has ignited the deadliest drug crisis in American history. Today, opioid overdoses kill an average of 115 Americans daily. Fatal drug use is on the rise in nearly every state, and the impact has been nothing short of catastrophic in Appalachia and the Midwest. But how is the opioid epidemic playing out in Texas? And will the crisis continue to escalate?
Drug Poisoning Death Rates by County (Age-Adjusted), United States, 2016
Source: Centers for Disease Control and Prevention
1. Texas has the third-lowest drug overdose death rate in the country.
While the opioid crisis is driving increases in drug overdose mortality nationwide, rates in Texas have not trended upward as sharply as other states. As a result, Texas ranks 48th of all states in drug overdose mortality, with a rate of 10.1 deaths per 100,000 population in 2016. Texas’ rate is about half the national average (19.8) and less than one-fifth that of the highest ranked state, West Virginia (52.0). Opioids account for about half of all drug overdose deaths in Texas, whereas they account for two-thirds of drug overdose deaths nationally.
Overdose Death Rates per 100,000 Population (Age-Adjusted), U.S. & Texas, 1999-2016
Source: Kaiser Family Foundation
2. Opioid use appears most prevalent in parts of north and east Texas.
Though Texas’ opioid overdose mortality rate is relatively low overall, county-level data reveal areas of the state where opioid use is a major concern. Opioid-related hospital admissions and accidental poisoning deaths are concentrated in North and East Texas, including many rural counties. Drug overdose mortality in some southeast Texas counties exceeded 24 deaths per 100,000 in 2016. Several counties along the Red River also have high rates of drug overdose deaths, including Baylor County (near Wichita Falls) with over 30 deaths per 100,000, highest of any county in the state.
Accidental Opioid-Related Poisoning Deaths in Texas by County, 1999-2015
Source: Texas Department of State Health Services
3. Legally prescribed opioid painkillers are involved in about half of opioid overdose deaths in Texas.
Many people with opioid use disorders first become addicted to opioid pain medication prescribed legally by a doctor. Emergency physicians, primary care physicians, dentists, and surgeons are leading sources of opioid prescriptions. Drug overdose mortality rates tend to be highest in areas where opioid prescribing rates are also highest.
Opioids Prescribed Per Person by County, 2015 (Morphine Milligram Equivalents)
Source: Centers for Disease Control and Prevention
As prescription painkillers become harder to obtain, some people with opioid use disorders transition to heroin use. Heroin has a similar effect on the body, and can be acquired illicitly for a fraction of the cost. Perhaps most concerning, the illicit drug supply is becoming tainted with dangerous synthetic opioids such as fentanyl. Approximately 50 times stronger than morphine, traffickers may mix fentanyl into heroin and cocaine to enhance its potency, dramatically increasing the potential for overdose. Nationally, fentanyl-related deaths nearly doubled from 2015 to 2016.
In 2017, roughly two-thirds of opioid related drug exposure calls to the Texas Poison Center Network were made for commonly prescribed opioids, while most of the remaining one-third were for synthetic opioids. Of 1,174 deaths in Texas involving opioids in 2015, 517 involved commonly prescribed opioids, 516 involved heroin, and 153 involved synthetic opioids.
4. Texas’ opioid problem could be about to worsen.
While illicit drugs laced with fentanyl are driving a recent wave of overdose deaths nationally, fentanyl was involved in only 4% of heroin deaths in Texas in 2017. Texas has been insulated from the lethal impact of fentanyl primarily because the most commonly used type of heroin in Texas, black tar, is harder to mix with fentanyl than the white powder heroin most prevalent in the Midwest and Appalachia.
But that could soon change. According to experts, white powder heroin use is increasing in Texas, drug suppliers are developing new ways to mix fentanyl with black tar heroin, and fentanyl is increasingly being mixed with drugs other than heroin. An uptick in opioid overdoses and deaths in Texas becomes more likely under these conditions.
5. Opioids are only one piece of the substance use crisis in Texas.
The current opioid epidemic has alarmed public health leaders and captured substantial media attention. But by several measures, opioids are hardly the leading addictive substance threatening the health of Texans.
Methamphetamine has long been the state’s top illicit drug threat, and currently more methamphetamine deaths occur annually than opioid deaths in Texas. Deaths involving prescription benzodiazepines (sedatives like Valium and Xanax) have quadrupled nationally from 2002 to 2016, and since they are often prescribed with opioids, have been described as an “epidemic within an epidemic.” And for many decades, alcohol has been the most frequently misused substance in Texas and the nation, responsible for 88,000 premature deaths per year nationwide and shortening the lives of those who die by an average of 30 years.
The common thread uniting these challenges is addiction, which has long been stigmatized as a behavioral problem or personal failing rather than a chronic, relapsing, and treatable disease. The emerging opioid threat is not the first substance use crisis Texas has faced, nor will it be the last. However, with the current urgency surrounding opioids, public health leaders in Texas have an opportunity to take a thoughtful approach to preventing and treating substance use, staying ahead of a problem that – at least for now – shows few signs of slowing.
Cossy Hough, LCSW
'This piece appeared in Texas Perspectives, the Houston Chronicle and the Austin American Statesman. See last post for more discussion about work requirements and Texas Medicaid from Anna Stelter.
The Trump administration has recently asked federal agencies to strengthen and expand existing work requirements for low-income Americans who receive public assistance through programs such as Medicaid and food stamps (Supplemental Nutrition Assistance Program or SNAP). Federal agencies have 90 days to review their current systems and propose policy changes.
Helping and empowering Americans living in poverty to be independent from public benefits is a worthy but complex goal. However, this effort is based on a simplistic analysis of public assistance and will harm the most vulnerable among us.
The Trump administration has pointed to Kansas as a success story because after the state strengthened the Temporary Assistance for Needy Families work requirements in 2011, caseload levels dropped and recipients received benefits for shorter periods. However, a recent study shows that one year after exiting the TANF program, nearly two-thirds of former recipients in Kansas had either no earnings or earnings below 50 percent of the poverty line. Work requirements may be effective in reducing welfare rolls but are clearly not as effective in reducing poverty.
An assumption under the administration’s request is that employment is the most effective way out of poverty and into self-sufficiency for Americans receiving public assistance. But low-wage jobs often do not generate enough income for individuals to achieve these goals.
Another issue is the instability of the low-wage labor market. Individuals receiving public benefits often work in industries such as food services and construction, in which both employment and hours are instable. The lack of flexibility in low-income jobs also means that workers may lose their job if a family disruption or a temporary lack of transportation forces them to take even a short amount of time off.
Many parents in low-wage jobs can’t afford full-time childcare or even after-school child care, and therefore working full-time is not an option for them. Demand for affordable childcare outweighs the supply across the country. According to the Afterschool Alliance, 18.5 million more children would participate in after-school programs if they were available in their communities. And yet, federal funding to help low-income parents pay for these programshas been declining.
Health also plays a factor that the Trump administration isn’t considering. States generally waive work requirements to receive public benefits for individuals with disabilities. Determination of a disability through the Social Security Administration is commonly accepted, but the process can take from one to three years and the average rate of denial is 53 percent. Approval of a disability claim for someone who can work intermittently due to chronic illness is unlikely. This leaves many Americans in the vulnerable position of being unable to work full time and unable to be declared disabled by the federal government. Strengthening work requirements for this population of Americans would be disastrous, especially if more people with chronic illnesses lose their Medicaid coverage. Without Medicaid coverage, people with chronic illnesses who live in poverty may find themselves both unable to work full time and unable to address their health needs.
Ultimately, the timing for this effort from the Trump administration is misjudged and the assumption that additional work requirement will impact the poverty rate in any meaningful way is shortsighted. SNAP enrollment and spending has been declining and is projected to continue to decline for the foreseeable future. The majority of families receiving SNAP benefits already had a working family member within the past year. The majority of non-elderly adults who receive Medicaid also work, most averaging over 80 hours of work per month. The executive order appears to be another attempt of the Trump administration to save money to the detriment of the vulnerable, including the 70 percent of SNAP households with children and the high numbers of children enrolled in Medicaid.
What legislators ought to do is reduce barriers to steady employment such as lack of childcare. And work requirements as a condition of health care coverage through Medicaid should be removed from consideration entirely. The realistic solution to address poverty in the U.S. is multi-layered as the problem itself and deserves more than an overly simplistic and ineffective solution.
Anna Stelter, LMSW, MPH
Update: The National Association of Social Workers has released a Medicaid Advocacy Toolkit to assist social workers in responding locally to efforts to establish Medicaid work requirements in their states.
Earlier this month, Arkansas joined Indiana and Kentucky as the third state to receive approval from the federal Centers for Medicare and Medicaid Services (CMS) to require enrollees in its Medicaid program to work. Beginning in April, non-disabled Arkansas adults under age 50 who are eligible for Medicaid will have to prove they are employed, in school, receiving job skills training, or performing community service at least 20 hours per week to maintain their health insurance coverage. CMS Administrator Seema Verma, explaining her agency’s support of work requirements, remarked “meaningful work is essential to beneficiaries’ economic self-sufficiency, self-esteem, well-being, and health.”
Requiring “able-bodied” Medicaid enrollees to work has emerged as a politically appealing option for states wanting to tailor who can enroll in the program and what benefits they receive. Nineteen other states, most with Republican governors, have asked CMS to allow them to administer a work requirement. However, Texas is one of a handful of GOP-led states that has not yet signaled an intent to require its Medicaid enrollees to work, and doesn’t seem likely to do so.
Because Texas’ approach to Medicaid policy has been in line with other conservative states now forging ahead with pursuit of work requirements, Texas’ decision not to join the pack might seem curious at first. Yet it’s precisely because of Texas’ conservative track record on Medicaid that it’s not in position to pursue a Medicaid work requirement. While Medicaid expansion states like Arkansas and Kentucky have a large share of working-age adult enrollees, Texas’ Medicaid program contains barely any enrollees to whom a work requirement could reasonably apply.
Status of Medicaid Expansion and Work Requirement Waivers, March 2018
Source: The Commonwealth Fund. Status of Medicaid Expansion and Work Requirement Waivers.
Who are Texas' Medicaid Enrollees?
Of the 4.5 million Texans enrolled in Medicaid, 94% are children, people with disabilities, and seniors, all of whom would be legally exempt from a work requirement under CMS rules. The 6% remaining are either low-income parents and pregnant women, young adults under age 26 who have recently exited foster care, mothers in domestic violence shelters, and other small segments of especially vulnerable enrollees. Texas did not expand Medicaid under the Affordable Care Act, and most low-income working-age adults are not eligible to enroll.
GOP policymakers have frequently suggested Medicaid should not be available to those who would rather rely on coverage from the government than work to earn coverage themselves. However, research hardly supports the suggestion people with Medicaid are unwilling to work. Almost all working-age adult Medicaid enrollees are already working (usually in jobs that do not offer health insurance), seeking work, attending school, or taking care of family members. Most of those who are out of work reported facing severe health-related barriers to work, such as chronic mental or physical illness. It is not clear which Texans a Medicaid work requirement would incentivize into work who aren’t legally exempt, currently employed, or have compelling reasons for not working.
Work Requirements could do More Harm than Good
Conditioning health coverage on work activities risks directly harming the health of out-of-work enrollees and their family members instead of promoting economic self-sufficiency. Under a work requirement, people who are temporarily unable to work for health reasons would lose their access to treatments, prescription drugs, or assistive devices that could facilitate their return to the workforce. People who provide full-time care for very young, ill, or disabled family members would be compelled to balance a job alongside the demands of unpredictable, round-the-clock caretaking, an impossible scenario for many families or employers to accommodate. And at a time when Texas is trying to reverse a statewide trend of rising maternal mortality rates, low-income pregnant and postpartum women who could not work during pregnancy or after delivery would lose access to potentially lifesaving care.
Work Requirements are Complex and Costly
If the mismatch between the target population for a work requirement and Texas’ actual enrollee population is not enough to dissuade state leadership, perhaps the complexity and the price tag is. A work requirement would saddle the state with a costly administrative burden (likely at least several million dollars annually) to create, operate, maintain, and staff systems to verify employment for thousands of enrollees. State leaders would also have to invest time and effort thoughtfully designing how the work requirement will be enforced: What activities qualify as “work”? What do enrollees have to do to prove they are working? How often must someone show proof?
A viable work requirement would have to be flexible enough to accommodate circumstances characteristic of low-wage work and poverty. For example, many low-income people move frequently, work cash-only jobs, lack control over the number of hours they work per week, have criminal histories, or lack a high school diploma, all of which could impact a person’s ability to seek, keep, and prove their employment.
The bottom line: While a politically popular move among many GOP-led states at this time, a work requirement in Medicaid is a bad fit for Texas.
Guest blogger, Vicki Hansen, ACSW
The enrollment period for the ACA Marketplace ended on December 16, 2017. For 6 weeks I volunteered as an enrollment specialist to help consumers apply, renew, or adjust their Marketplace insurance plans.
A lot has happened politically since I retired as executive director of the Texas Chapter of the National Association of Social Workers in 2014. During my nearly 20 years there, I worked on public policies that included healthcare. Social workers have long been involved in helping to shape healthcare policy and it is essential that we continue. Watching what was happening to the ACA and to CHIP under the current administration made it impossible for me to do nothing. I wanted to get back into the trenches and see the people who were being affected; I wanted to help people get the health care services they needed – I wanted to get back in the field.
I received 40 hours of training provided through the amazing nonprofit Foundation Communities. I shadowed an experienced person (also volunteer) for a few hours and then I started enrolling people on my own. I’ve rarely felt so incompetent …by the time the 6 weeks was over I was chomping at the bit to do this again next year.
The array of situations that caused people to need low cost healthcare was both expected and surprising. Citizenship is required to be eligible so everyone I worked with was either born here or a naturalized citizen. Most of the people who came in were worried or angry, but mostly grateful. I’ll share a few of their stories –
Many of the clients I had were musicians - important to the economy in Austin, but are generally self-employed with no benefits. They generally seem to earn between $11,000 and $30,000 a year. Between the ACA tax credits and various public and private partnerships, they pay anywhere from $25 -$100.00 a month - everything else is underwritten. They were SO grateful and appreciative. It was a great experience. Another client works as a dishwasher for a restaurant. He is an older man who earns about $900 a month with no benefits. His wife is ill and cannot work. He also, was so grateful for the ACA. One of the most challenging clients was a white man in his late thirties. He works 3 jobs to make ends meet and was very angry about the dramatic increase in his premiums from last year and the direction of the country. It was hard not to engage in his rage.
Most of the people I worked with work part-time with no benefits. Ride – sharing, music, photography, restaurant work, hair stylists and landscapers. They were generally people who had little control over how much they worked and were never offered benefits. Some of them are HIV positive, some of them have Type I diabetes. One person is a kidney transplant recipient – his wife was his donor. He is a blue collar worker who will be on expensive medications the rest of his life.
For many of the people I met during this process, I am simply worried about their future. I will continue to be in touch with my legislators and continue to advocate for change. I hope you will do the same.
By guest blogger Liana Peruzzi, LMSW
As a medical social worker, the continual attempts to repeal and replace the Affordable Care Act (ACA) over the past year has caused a lot of uncertainty and anxiety among my patients. And if I’m being honest, it has caused me a lot of uncertainty and anxiety as well. I work primarily with adults who have a chronic conditions such as diabetes, hypertension or congestive heart failure, so maintaining access to medical care and medications is essential for them; living without insurance could be a life or death situation. It can be difficult enough to find affordable health insurance for low or middle income clients with a chronic illness in Austin, partly because Texas did not expand Medicaid. The prospect of a repeal and replace alternative that offered more limited coverage with higher premiums inevitably meant that some of my clients would have to choose between keeping a roof over their head and having access to medically necessary care. Needless to say, I breathed a sigh of relief when Congress could not pass a repeal and replace act in time for this year’s open enrollment.
While insurance companies have been doing their best to keep the marketplace stabilized in the face of opposition from Congress and tepid support from the White House, President Trump’s recent decision to end the Cost Sharing Reduction (CSR) Program in 2018, citing lack of appropriated funding for the program, has made this even more difficult. Insurance companies have been trying to determine if they want to stay in the marketplace based on whether the federal government would continue financially subsidizing healthcare for low and middle income Americans. But what is the CSR program, and how does it impact low and middle income people?
The Affordable Care Act has many cost reduction components built into the policy to insure that low-income Americans can still access affordable healthcare. The legislation currently requires that the cost of marketplace coverage is income-based. Therefore, the government currently subsidizes certain costs associated with health insurance. For example, premium tax credits are available for people between 100% and 400% the federal poverty limit (approximately $48,000 or less for a single adult) and these are currently paid by the federal government. The Cost Sharing Reduction (CSR) program is similar as it provides further financial assistance for co-pays and deductibles for people between 100 and 250% of the poverty limit (approximately $30,000 or less for a single adult) to keep down out of pocket costs. For example, in a typical silver plan, the insurance company pays 70% and the individual pays 30%. However, for those that qualify for CSR, that individual amount could be reduced to as low as 6%.
Up until recently, this program was being subsidized by the federal government. However, on October 12th President Trump wrote an executive order that ended federal funding for the CSR program starting in 2018. President Trump has been open about his opposition to the Affordable Care Act and his belief that the marketplace is failing. Since repeal and replace legislation have failed, this was his only way to weaken the marketplace without congressional support. So what does this mean for the 2018 marketplace and for ACA enrollees?
1. This does not impact the cost of marketplace coverage for people with low incomes (FPL 100-250%). First, it is important to highlight that this does NOT end the cost sharing reduction program for those that qualify, as it is a cost-saving mechanism built into the Affordable Care Act. Rather, it shifts the cost from the federal government to the insurance companies. And since insurance companies legally have to cover the costs, they will be shifting the additional costs to higher income enrollees. Many insurance companies already increased their 2018 premiums in anticipation that this might happen, and the national average increase is 34%.
2. This does not impact the cost of marketplace coverage for middle income people (FPL 250-400%).
Second, it is important to note that the federal government will still be providing tax subsidies to anyone who is under 400% FPL. So this means that the increase in premiums for people that qualify for tax subsidies will actually be paid for by the government. Some estimates suggest 80% of people enrolled in marketplace coverage receive some kind of tax subsidy, so this is good news for the majority of Americans. Unfortunately, this will put a higher financial burden on the federal government, because they will now have to subsidize more expensive health insurance premiums. The Congressional Budget Office estimates that this will add approximately $6 billion to the federal deficit in 2018, $21 billion by 2020 and $26 billion in 2026.
3. This does impact the cost of marketplace coverage for upper middle-income people (over FPL 400%).
The group of individuals who will be hardest hit by this legislation are people who are making more than 400% FPL (approximately $48,000 or more for a single adult). This group makes up about 20% of the overall marketplace. A quick search on healthcare.gov showed premiums ranging from $633-945 per month for a 55 year old male making $55,000 in Texas. Generally, the higher your monthly premium, the lower your deductible and out of pocket costs. However, for the $945/month silver plan, the deductible is still $3500 and the out of pocket maximum is $7350, which is incredibly high. For comparison, someone who qualifies for the CSR program would have a deductible between $550 and $1950 and out of pocket maximums for $2450 or less.
The Bottom Line
Trump’s decision to end the CSR program will not impact the majority of Americans enrolled in the marketplace. 84% of people enrolled in the marketplace are eligible for tax subsidies, which protects them from paying an increase in premiums, deductibles or out of pocket costs. That said, the cost of insurance will still increase, and the government will end up paying approximately $6 billion more in health care costs now that the CSR program has been cut. As for the 20% of Americans that do not qualify for premium tax subsidies, their premiums will increase by 20-34%, which could force people to go without insurance and pay out of pocket for preventive and routine medical care. And while there is at least one marketplace option in all Texas counties, this does not guarantee that patients can keep their established primary care and specialty doctors. The marketplace’s recent instability has led to many plans exiting and entering the marketplace at the last minute and could force patients to enroll in new coverage without the guarantee that their doctors will take a new plan. This could mean more struggles for my clients as they continue to seek solutions to getting the medical care they need.
Will Francis, LMSW
Government Relations Director,
National Association of Social Workers,
Cossy Hough, LCSW
Clinical Assistant Professor, The University of Texas at Austin,
School of Social Work
Anna Stelter, LMSW, MPH
Health Policy Analyst
Texas Health Institute
Alison Mohr Boleware, MSSW
Mental Health Policy,